Avoid common mistakes on your manuscript.
Introduction
Cryptococcosis is the most common mycotic infection of the central nervous system (CNS). It more frequently occurs as an opportunistic infection in patients with either human immunodeficiency virus (HIV) infection or other immunocompromised conditions. CNS cryptococcosis primarily manifests as meningitis [1]. The pseudocysts and the granulomas of the choroid plexuses were reported to be specific findings on magnetic resonance imaging (MRI) [2]. We describe here a HIV seronegative case of cryptococcal meningoencephalitis presenting multiple gelatinous pseudocysts.
Case report
A 35-year-old woman with a history of autoimmune hemolytic anemia and longtime prednisone taken presented with headache, fever and altered mental status. Neurological examination revealed meningeal irritation and bilateral pathological reflex of Babinski sign. Brain MRI showed bilateral and multiple hypointense T1 (not shown) and hyperintense T2 soap bubble-like gelatinous pseudocysts at the periventricular white matter, basal ganglia, midbrain and dentate nucleus, with mild post-gadolinium enhancement at bilateral basal ganglia (Fig. 1 a–e). Lumbar puncture was performed with cerebral spinal fluid (CSF) pressure of 350 mmH2O. CSF was clear with a protein level of 359 mg/L (normal range: 150–450 mg/L), a glucose level of 0.54 mmol/L (normal range 2.22–3.89 mmol/L), but without leukocytes. India ink staining of CSF found Cryptococcus neoformans (Fig. 1f) and fungal spores. Fungal culture and cryptococcal capsular polysaccharide antigen test of CSF confirmed CNS cryptococcal infection. Subsequently, blood culture also revealed cryptococcal infection. Serum HIV test of this patient was negative. However, lymphocyte count in the peripheral blood was as low as 0.03 × 109/L (normal range: 1.10–3.20 × 109/L). Peripheral blood lymphocyte subsets analysis revealed a significant reduction of all kinds of immune cells, especially the extremely reduced CD4 + T lymphocytes and NK cells (Table 1). Ultrasonography showed splenomegaly. Based on these findings, cryptococcal meningoencephalitis was diagnosed in this immunocompromised patient. Though received standard antifungal treatment, the patient died of cerebral hernia 3 weeks later.
Discussion
Cryptococcosis in most cases affects patients with acquired immune deficiency syndrome (AIDS). Less frequently, it can be found in other immunocompromised patients. In this case, the HIV seronegative patient had a history of autoimmune hemolytic anemia after she gave birth to her second baby. She took prednisone orally for 7 months and then stopped for 12 months before this onset. Anemia no longer existed. However, the extremely low peripheral blood lymphocyte count and the absence of leukocyte reactivity in CSF were clues of immunosuppression. Peripheral blood lymphocyte subsets analysis revealed a significant reduction of T lymphocytes and NK cells, which helped confirming immunodeficiency.
Meningitis pronounced at the base of the brain is the primary pathological lesion of CNS cryptococcosis. Occasionally the meningeal infection can extend along perivascular spaces and give rise to small cysts in the Virchow–Robin spaces and adjacent brain, which term gelatinous pseudocysts [3]. Gelatinous pseudocysts exhibit soap bubble appearance by MRI, with a low to intermediate T1WI signal, a high T2WI signal and a low T2-FLAIR signal [4, 5]. In immunocompromised patients, the enhancements of the cystic lesions and meninges are usually mild or absent. These lesions can help the diagnosis of cryptococcal meningoencephalitis.
References
Mourad A, Perfect JR (2018) The war on cryptococcosis: A Review of the antifungal arsenal. Mem Inst Oswaldo Cruz 113(7):e170391. https://doi.org/10.1590/0074-02760170391
Andreula CF, Burdi N, Carella A (1993) CNS cryptococcosis in AIDS: spectrum of MR findings. J Comput Assist Tomogr 17(3):438–441
Caldemeyer KS, Mathews VP, Edwards-Brown MK, Smith RR (1997) Central nervous system cryptococcosis: parenchymal calcification and large gelatinous pseudocysts. AJNR Am J Neuroradiol 18(1):107–109
Corti M, Villafañe MF, Negroni R, Arechavala A, Maiolo E (2008) Magnetic resonance imaging findings in AIDS patients with central nervous system cryptococcosis. Rev Iberoam Micol 25(4):211–214
Vieira MA, Costa CH, Ribeiro JC, Nunes-Filho LP, Rabelo MG, Almeida-Neto WS (2013) Soap bubble appearance in brain magnetic resonance imaging: cryptococcal meningoencephalitis. Rev Soc Bras Med Trop 46(5):658–659. https://doi.org/10.1590/0037-8682-0142-2013
Funding
This study was supported by the Hubei Provincial Natural Science Foundation of China (Grant No. 2018CFB115) and the National Natural Science Foundation of China (Grant No. 81671064, 81371222).
Author information
Authors and Affiliations
Contributions
PZ: preparation of manuscript, literature review. LL: acquisition of data. FW: review and supervision of manuscript.
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
The authors certify that they comply with the Principles of Ethical Publishing.
Informed consent
The patient has given her informed consent.
Rights and permissions
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
About this article
Cite this article
Zhang, P., Lian, L. & Wang, F. Magnetic resonance imaging features of gelatinous pseudocysts in cryptococcal meningoencephalitis. Acta Neurol Belg 119, 265–267 (2019). https://doi.org/10.1007/s13760-018-1033-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13760-018-1033-6